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Thursday, December 22, 2011

Semmelweis and the great Handwashing mystery

In Vienna in the early 1800s two wards of the General Hospital delivered babies. In Ward One the babies were delivered by medical students and in Ward Two by midwives. Both wards were free and provided care to the poorer women of Vienna, yet strangely Ward One had a very poor reputation outside the hospital.

This had nothing to do with the care the women received from their medical professional. The techniques of delivery were the same whether performed by medical students or midwives. Yet in Ward Two the death rate from ‘childbed fever’ was 4-5%. In Ward One it was double that at 9- 10%.

Childbed fever was a horrid illness that is virtually unheard of today. Aftrr birthing her baby a young woman would develop an high fever, abdominal pain and virulent red streaks across her belly (erysipelas). Eventually this overwhelming infection would result in unconsciousness and death.

At the time, no one was overly interested or concerned about this disparity. The difference between the care these patients received was only in who provided the care. What seems so obvious to us now was simply not seen by the practitioners of the day. Childbed fever was known to occur in clusters. Even though this kind of ongoing affliction could not have a random basis, it was accepted because there was no better explanation. Keep in mind that this was all some fifteen years before Louis Pasteur came up with the concept of bacteria.

Up until a young physician named Semmelweis came along.

Ignaz Philipp Semmelweis (1818-1865) was born in Buda, Hungary. He studied medicine at the Universities of Pest and Vienna. In 1846 he was appointed to the General Hospital in Vienna.

It is important for us to note that Semmelweis had been greatly affected by the death of his friend, Jakob Kolletschka some years prior. Kolletschka, a professor of forensic medicine, had cut his finger whilst performing a post-mortem examination. Gloves, of course, were not brought into widespread use until some fifty years later. Kolletschka had developed an high fever, abdominal pain and erisypelas and had quickly passed away.

To modern day doctors, this is the classic presentation of septicaemia, or blood poisoning.

Semmelweis noted that women who had their babies outside the hospital, prior to admission, rarely suffered from childbed fever. He also noted that medical students would attend deliveries straight after handling corpses in the autopsy room. He deduced that the medical students were carrying some kind of poison on their hands which was infecting the labouring women.

As a result he insisted that anyone in the hospital attending the delivery of a baby would first have to wash their hands in chlorinated water. Within a year the mortality rate from childbed fever in both Ward’s One and Two had dropped to one percent.

Despite this success, Semmelweis’s changes were deeply resented by the medical fraternity. Doctors of the time were actually proud of the ‘hospital odour’ they carried on their hands, considering it as a mark of their status. Semmelweis's protocol for handwashing was also time consuming. Similarly, they were angry at the suggestion that they could have been responsible for the women’s deaths. Semmelweis published several papers of his findings, which were ignored, and he was eventually forced out of his job in 1850.

Undettered, he began teaching midwifery at the Pest University, and continued to publish papers. In 1861 he published a book, his seminal work, entitled Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers (the Cause, Theory and Prevention of Childbed Fever).

Unfortunately this was a rambling and dense tome where the point about handwashing was deeply buried and not easily extractable or understandable. Unsurprisingly that most important conclusion, therefore, fell on deaf ears.

The book was probably one of the first signs of Semmelweis impending breakdown. He became increasingly irrational and psychotic and was eventually admitted to a mental hospital. Here he became violent and was beaten by attendants. As a result of the injuries he suffered, he developed blood poisoning, and passed away some two weeks later.

The cause of Semmelweis’s own breakdown is unclear. It’s somewhat romantic to think that that the ignorance and frustrations of the medical profession caused him to go insane. However, it is much more likely that he already suffered a psychotic tendency and his professional frustration was simply the trigger.

Either way, the cause of his death is deeply ironic.

As to the actions of the maternity community, Semmelweis's work was largely unknown. Fourteen years after his death, a gynaecologist went to present a paper denouncing the idea that a contagion was responsible for childbed fever. Fortunately, Louis Pasteur was present at the same conference, and the great man stood up and silenced the audience with the announcement that a bacteria, streptococcus, was the causative agent. That’s when things finally began to change.

3 comments:

It's amazing, verging on unbelieable, that doctors of the time wanted their hands to smell like their work. Incredible! And even more amazing that they denied the hand-washing had anything to do with the corresponding decrease in the fever. I'm so glad things have moved on considerably since then (and it makes me wonder which current practices will look archaic and horrible two hundred years from now).

It's strange - I work in construction, and there is a certain demographic that takes pride in doing things like handling wet concrete (very caustic) with bare hands. It could be some sort of misplaced pride?

I agree with Katie though - while it's scary to look at how bad things were only 150 years ago, it's almost exciting to wonder what we will be able to improve next.